三维重建技术在腹腔镜肝切除中的应用

发布时间：2018-04-30 18:41

  本文选题：三维重建 + 腹腔镜　； 参考：《浙江大学》2017年硕士论文

【摘要】：目的:近年来,得益于三维重建技术等信息化产业以及多产业的融合发展,肝脏手术逐渐从"彻底切除病灶"至"精准肝切除"理念改变,精准肝切除理念在肝脏外科领域得到诸位大家支持,国内黄志强院士以及董家鸿教授等人先后指出,精准肝切除可以使肝脏手术患者达到最优的疗效及康复体验。肝脏外科正式迎来精准肝切除时代。文旨在探究微创医学领域下的肝脏外科精准外科理念,也就是三维重建联合腹腔镜下肝脏切除手术的优劣,进一步推广普及肝脏三维重建技术以及腹腔镜肝脏手术,一则减轻术中损伤,提高手术质量;二则加快患者康复。资料和方法:浙江大学医学院附属邵逸夫医院从1998年开始开展腹腔镜肝脏手术,至今已经积累了腹腔镜肝脏手术1000余例,有着深厚的腔镜底蕴。从2014年起本院也逐步采用肝脏三维重建技术用作肝脏手术的术前指导,积累了 100余例病例,技术日益成熟。本文统计从2014年1月到2016年8月行腹腔镜右半肝切除,腹腔镜局部肝脏切除病例共94例。所有病例均统计术前指标如一般情况,肿块位置,肿块大小,肝内脉管走行等。术中指标统计手术方式、手术时间、术中出血、中转、输血率等,术后指标统计术后并发症和住院时间、住院费用等。分别比较腹腔镜大部分肝切(以腹腔镜右半肝为例)和腹腔镜局部肝切有无术前行三维重建对术前评估,术中指标以及术后指标的影响。结果:将本中心94例肝脏手术患者按照:1.三维重建联合腹腔镜大部分肝脏切除,2.单独腹腔镜大部分肝脏切除,3.三维重建联合腹腔镜局部肝脏切除,4.单独腹腔镜局部肝脏切除分为四组。对各组病例术前资料进行评估,除了大部分肝脏切除病例患者的ALT水平,以及局部肝脏切除的男女比例这两项重建组与非重建组有一定的显著性差异外,其他各组不管是在年龄还是既往腹部手术史、肝硬化等方面都与其他组无明显统计学差异。同时也对腹腔镜大部分肝切除和腹腔镜局部切除的重建组与非重建组手术难度进行了对比分析,采用新难度评分系统,得出大部分肝切重建组难度评分10.17±1.528对比非重建组10.61±0.778;P = 0.07;以及局部肝切重建组难度评分5.73±1.849对比非重建组4.94±2.193;P = 0.598;两组资料对比均无显著性差异。腹腔镜大部分肝切除和腹腔镜局部肝切的重建组与非重建组基本资料以及手术难度一致,术前资料有一定可比性。术前指标如脉管变异,统计结果发现,在所有重建患者中,肝动脉,门静脉,肝静脉均正常的患者比值为60.8%;门静脉Ⅱ型变异13.0%,Ⅲ型变异8.6%,肝动脉Ⅵ型变异4.3%。术中指标如手术时间,术中出血,中转,在腹腔镜大部分肝脏切除组中,术中出血指标重建组475±263.3 ml对比非重建组972.2±811.5ml;P=0.044,以及中转指标重建组0%对比非重建组56%;P = 0.002,均具有显著性差异。在腹腔镜局部肝脏切除组中,手术时间重建组172±45.4min对比非重建组186.8±83.3 min;P = 0.014,具有显著性差异。术后指标如并发症,在腹腔镜大部分肝脏切除组中,Ⅲ级及Ⅲ级以上并发症重建组0%比非重建组27.8%;P=0.046,具有显著性差异。而术后指标在腹腔镜局部肝切组中对比不明显,无明显显著性差异。结论:腹腔镜肝大部分切除术的患者术前行三维重建可有利于术者进行术前评估,导航术中操作,减少术中术后并发症,加快手术患者康复。但在局部肝切除中的患者中,三维重建所带来的效益并不是很明显。
[Abstract]:Objective: in recent years, thanks to the three dimensional reconstruction technology and the integration of multi industry, liver surgery has gradually changed from "complete resection of focus" to "precise liver resection", and the concept of precision hepatectomy has been supported by all people in the field of liver surgery. Academician Huang Zhiqiang and Professor Dong Jiahong, in the country, have pointed out that Para hepatectomy can enable patients with liver surgery to achieve the optimal efficacy and rehabilitation experience. Liver surgery is formally ushered in the era of precision hepatectomy. The aim of this study is to explore the precise surgical philosophy of liver surgery in the field of minimally invasive medicine, that is, the advantages and disadvantages of three-dimensional reconstruction combined with laparoscopic hepatectomy, and further popularize the three-dimensional reconstruction of the liver. Technology and laparoscopic liver surgery, one can reduce the injury in the operation, improve the quality of the operation, and two speed up the patient's recovery. Data and methods: the Sir Run Run Shaw Hospital affiliated to the Zhejiang University medical school began to carry out laparoscopic liver surgery in 1998. So far, more than 1000 cases of laparoscopic liver hand surgery have been accumulated. The hospital has also gradually used three-dimensional reconstruction of the liver as a preoperative guidance for the operation of the liver. More than 100 cases have been accumulated, and the technology is becoming more and more mature. From January 2014 to August 2016, the laparoscopic right hemihepatectomy and 94 cases of laparoscopic local hepatectomy were performed. All cases were statistically analyzed before the operation, such as the general condition, the swelling position, and swelling. The size of the block, the intrahepatic vein and so on. In the operation, the operative methods, the operation time, the intraoperative bleeding, the transfer, the rate of blood transfusion, the postoperative complications and hospitalization time, the hospitalization expenses, etc. were statistically compared. The preoperative three dimensional reconstruction of the laparoscopic most liver resection (with the laparoscopic right Hemiliver as an example) and the laparoscopic local liver resection were performed before the operation. Results: 94 cases of liver surgery in the center were treated with 1. three dimensional reconstruction combined with laparoscopic most liver resection, 2. separate laparoscopic hepatectomy, 3. three-dimensional reconstruction combined with laparoscopic partial hepatectomy, and 4. separate laparoscopic partial hepatectomy in four groups. Preoperative data were evaluated. Except for the ALT level of most cases of hepatectomy and the proportion of men and women with local hepatectomy, there was a significant difference between the two reconstructive groups and the non reconstruction group. The other groups were not significantly different from the other groups in age or previous abdominal surgery history and liver cirrhosis. The difficulty of the reconstruction group and the non reconstruction group was compared. The difficulty score of the most liver resection group was 10.17 + 1.528 compared to the non reconstruction group of 10.61 + 0.778, P = 0.07, and the difficulty score of the local liver resection group was 5.73 + 1.849 compared with the local liver resection group. The non reconstructive group was 4.94 + 2.193; P = 0.598; there was no significant difference in the data of the two groups. The basic data and the difficulty of the operation in the reconstructive and non reconstructive groups of the laparoscopic and laparoscopic partial hepatectomy and the non reconstruction group were consistent. The preoperative data were comparable. The ratio of normal patients with vein, portal vein and hepatic vein was 60.8%, the variant of portal vein type II was 13%, type III variant 8.6%, and the index of hepatic artery VI variant 4.3%., such as operation time, intraoperative hemorrhage and transfer, was 475 + 263.3 ml in the rebuilt group of intraoperative bleeding index in the majority of laparoscopic hepatectomy group, compared with 972.2 811.5ml in non reconstruction group; P=0.044, And the reconstructive group 0% compared with non reconstruction group 56%, P = 0.002, with significant differences. In the laparoscopic local hepatectomy group, the operation time reconstruction group was 172 + 45.4min compared to the non reconstructive group of 186.8 + 83.3 min; P = 0.014, with significant difference. 0% of the above complications were compared to non reconstruction group (27.8%) and P=0.046, with significant difference. The postoperative indexes were not obvious in the laparoscopic local liver resection group, and there was no significant difference. Conclusion: the preoperative three-dimensional reconstruction of the patients with laparoscopic hepatectomy can be beneficial to the preoperative assessment, navigation operation, and reduction of the operation. Postoperative complications can accelerate the recovery of patients. However, the effect of three-dimensional reconstruction is not very obvious in patients undergoing local hepatectomy.

【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.7
，

本文编号：1825721